SLYC Student Registration Form

SLYC Student Registration Form

Fill out the form carefully for registration
Student Name*

First NameMiddle NameLast Name
What is the age of your youth?
What is your youth date of birth?*

YearMonthDay
Gender
Identified Race:*

African American/BlackCaucasian/WhiteHispanicAsianAmerican IndianIndian/Pacific IslanderOther
Student Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
What county does your youth reside in?
Student E-mail*
If not applicable, type N/A
School/College/University Name*
Grade/College/Vocational College Level*
Major/Field of Study*
If not in college type N/A
Interests/Hobbies*
How did you hear about us?*
Type who or where did you find out about SLYC International
Parent/Guardian Name (1) if applicable*

First NameMiddle NameLast Name
Parent/Guardian (1) Phone Number *
If student is under 18 years of age
Parent/Guardian (1) E-mail*
example@example.com (if student is under 18 years of age)
Parent/Guardian Name (2)

First NameMiddle NameLast Name
Parent/Guardian (2) Phone Number
Parent/Guardian (2) E-mail
example@example.com
Signature (Parent Signature Required for students under 18 years of age)*

Clear
By signing this form, you give permission for SLYC International to take pictures, video and etc. and use for advertisement of all programs, classes and activities.
Should be Empty: